Lambeth and Southwark clinical commissioning groups (CCGs) delivered pharmacist-led virtual clinics to ensure all atrial fibrillation (AF) patients at risk of stroke were offered anticoagulation, if appropriate.
Over a 12-month period, the programme reviewed over 1,500 patients with AF not receiving anticoagulation, which resulted in an additional 1,200 patients being anticoagulated. The 2 CCGs have since seen a 25% reduction in the rate of AF-related stroke.
Locally and nationally it was recognised that the rates of anticoagulation in AF were sub-optimal and that there was significant variation in treatment between CCGs and between individual GP practices, including variation in rates of exception reporting.
In addition, the Sentinel Stroke National Audit Programme (SSNAP) data demonstrated that over 50% of patients presenting with stroke and known AF prior to admission, were not receiving anticoagulation at the time of the stroke.
The CCGs recognised that the rate of anticoagulation in AF could be increased through systematic clinical review of all patients with AF, who were not currently prescribed anticoagulant therapy by a specialist anticoagulation pharmacist.
What was involved
A Prescribing Improvement Scheme (PIS) was developed, which involved:
A practice level audit of all AF patients not anticoagulated.
Delivery of in-practice virtual clinics led by specialist anticoagulation pharmacists, during which treatment options were discussed with the practice prior to patient follow up. These options included warfarin or direct oral anticoagulants or, where anticoagulation was contraindicated, insertion of a left atrial appendage occlusion device in appropriate patients. An individualised management plan was agreed for each patient.
Implementation of the patient management plans by the GP practice, for which the practice submitted outcomes to receive payment as defined by the prescribing improvement scheme
The virtual clinic discussions sought to address the myths and misconceptions associated with the use of anticoagulation in AF. The discussions focused on specific patient groups who are often not optimally treated. For example, patients who are housebound, frail, have fallen or bled in the past and those with cognitive impairment. The aim was to equip frontline GP practice staff to effectively assess and treat these patients in future to ensure the outcomes of the programme were sustained.
What went well
As a result of the programme, over a 12 month period, the management of over 1,500 people with AF not receiving anticoagulant therapy was reviewed across 91 GP practices in Lambeth and Southwark CCG, At the end of the programme, an additional 1,200 people with AF were anticoagulated and, over the 3 years since then, the rate of AF-related stroke across the 2 CCGs has fallen by 25% (compared to a 3% fall nationally).
Central to the success of the programme was:
- the identification of credible specialist anticoagulation clinicians to lead the virtual clinic discussions because many of the untreated patients were complex and required careful weighing up of the benefits and risks of anticoagulation
- integration of the programme into the local PIS to maximise GP engagement and ensure practices were paid for the additional work undertaken to deliver the programme
CCG support, recognising that the identification of AF patients suitable for anticoagulation therapy would increase drug expenditure, although savings would be realised elsewhere in
the system through reduced stroke rates
The programme was very well received by GP practice staff and it strengthened the relationship between the anticoagulant pharmacists, seconded from secondary care, and the GP practice staff.
This resulted in the pharmacists redesigning the anticoagulation referral form across the 3 local acute trusts to standardise the referral process for GP practices. It also led to the pharmacists supporting ‘virtual initiation’ of direct oral anticoagulant therapies for housebound patients in primary care avoiding the need for referral for this less mobile cohort.
What could be improved
A number of issues arose during the delivery of the programme.
After the pharmacists had visited the first few practices, we implemented a standardised search to assist practices in identifying the patients requiring a review, in order to ensure all appropriate patients were discussed at the virtual clinics.
The programme led to a large number of referrals to the local anticoagulant service for the initiation of anticoagulation, which resulted in a temporary rise in waiting times. It was important to ensure that the waiting time was short before the project began and that the anticoagulant services were prepared for the increase in referrals to ensure patients identified as requiring anticoagulation received treatment in a timely manner.
The programme has been rolled out by the Health Innovation Network for South London to 2 further CCGs and this has resulted in similar increases in the rate of anticoagulation and reductions in AF related strokes. This virtual clinic model is being used locally to address other areas of unmet clinical need for people with diabetes, chronic obstructive pulmonary disease and hypertension.
Helen Williams, Consultant Pharmacist for CVD, Southwark CCG, Clinical Adviser for AF, AHSNs Network, CVD Clinical Lead, Lambeth CCG